Wake up and smell the coffee

April 2013 Vol 13 (4)

CLINICALLY APPRAISED TOPIC (CAT): Is ‘prescribing’ a post-surgery long black good for the bowels as well as morale?

CLINICAL BOTTOM LINE:
The addition of regular espresso coffee the day after surgery – involving a fast-track colorectal surgical protocol – accelerated time to first bowel motion without undue effects for elective patients.

CLINICAL SCENARIO:
Although British science writer Ben Goldacre notes coffee both increases and decreases the risk of cancer, as a committed coffee drinker you are ever alert to its possible benefits. A recent notification reveals the effects of coffee may extend into improving patient outcomes in surgical nursing. You investigate further.

QUESTION:
Among adults having bowel surgery, does coffee hasten return to normal bowel function compared to usual care (hydration using water)?

SEARCH STRATEGY:
No search strategy – paper notified through push mechanisms (Evidence Update)

CITATION:
Muller SA, Rahbari NN, Schneider F, et al. Randomized clinical trial on the effect of coffee on postoperative ileus following elective colectomy. BR J SURG 2012;99:1530-38.

STUDY SUMMARY:
Open-label randomised controlled trial in three German teaching hospitals, conducted from May 2010. 103 patients were screened and 80 randomised. Patients must have been aged at least 18 years and been scheduled for open or laparoscopic colon surgery for benign or malignant disease. Patients were excluded if a rectal resection, stoma or multivisceral resection was planned, had a known sensitivity to or distaste for coffee, or had impaired cognition. Fast-track surgery principles were applied to all patients (no mechanical bowel preparation; no oral antibiotic therapy; one preoperative enema for patients receiving left hemicolectomy or rectosigmoid resection; single dose of antibiotic prophylaxis at anaesthetic induction; and low molecular weight heparin and compression stockings). Postoperative feeding was standardised – water was first offered six hours after the operation, liquid food on day 1 and solid food on day 2 post-op. Patients were instructed not to drink any tea or extra coffee, but could drink any amount of mineral water they wished.

Intervention: Three cups of coffee daily (100 ml LaVazzo Blue Espresso Dolce 100% Arabica, 8 gram per coffee capsule, given at 0800, 1200 and 1600) beginning on the morning after surgery. Patients were asked to drink all the liquid within ten minutes and no additives (milk, sugar) were allowed.

Control: Three cups of warm water daily (100 ml at 0800, 1200 and 1600) beginning on the morning after surgery.
Outcomes: Primary outcome was duration of postoperative ileus after surgery using time to first bowel movement as a surrogate for duration of ileus. Secondary outcomes included time to tolerance of solid food, time to first flatus, need for laxatives, safety and length of stay.

STUDY VALIDITY:
Randomisation was by 1:1 allocation without stratification by centre. The allocation concealment was through sequentially numbered, opaque, sealed envelopes stored in a central office with allocation made by contacting study manager. One patient (1%) in control arm was removed as did not have planned surgery. Analysis was by intention to treat. The trial was open-label with investigators, staff and participants aware of allocation. The groups were similar for important factors (diagnosis, types of procedure, co-morbidities, ASA grade, duration of operation and epidural anaesthesia) and there was no evidence that participants were not treated equally. Overall the methodological quality of the study was high.

RESULTS:
Time to first bowel movement (BM) was significantly earlier for the coffee group (see table). Other outcomes were not significantly different. Using coffee did not increase nasogastric tube reinsertions, anastomotic leakage or need for laxatives and the rates for these safety variables were all lower in the coffee arm.

COMMENTS:
The coffee was well-tolerated by patients – only ten per cent of patients did not want coffee the day after surgery.
Patients received prepared espresso. It is not known whether the treatment effect would remain if instant coffee was substituted.
The heterogeneity of the sampled patients reflects the reality of elective surgical practice.
An unexplored benefit of including espresso coffee in patient care may be a counterbalancing effect on staff morale.

Reviewer: Dr Andrew Jull, RN PhD, Associate Professor, University of Auckland & Nurse Advisor – Quality, Auckland District Health Board. 

Table: Outcome data and 95% confidence intervals
 Time to first BM  60.4 hours  74.0 hours  6.6 hours
 (-5.4 to 18.4)
 0.006
 Time to solids  49.2 hours  55.8 hours  6.6 hours
 (-5.4 to 18.4)
 0.276
 Time to flatus  40.6 hours  46.4 hours  5.8 hours
 (-3.5 to 15.2)
 0.214
 Length of stay  10.8 days  11.3 days  0.5 days
 (-1.5 to 2.6)
 0.497
 Outcome  Coffee  Control  Absolute difference
 (95%CI)
 P value